PCCN UPDATED SCRIPT 2026 PRACTICE
SOLUTIONS GRADED A+
● A post-STEMI (ST elevation myocardial infarction) patient is started
on an angiotensin-converting enzyme (ACE) inhibitor during his
hospital stay. Which of the following is the most common serious side
effect that may occur?
A. a nonproductive cough
B. pedal edema
C. swelling of the tongue and face
D. rhinorrhea. Answer: C. swelling of the tongue and face
Although all of the answers may occur, swelling og the tongue and face
is the most serious and may require intervention. Patients should be
instructed to seek medical attention immediately for any signs of
swelling in the tongue or throat.
● Which of the following best describes the fourth heart sound (S4):
A. It occurs after ventricular contraction
B. It is best heard with the diaphragm of the stethoscope
C. It is a normal finding in children
D. It occurs during late diastole when the atria contracts. Answer: D. It
occurs during late diastole when the atria contracts
The presence of the extra heart sound S4 signifies a poorly compliant
(stiff) left ventricle. An S4 is also called an atrial heart sound since it
,occurs at the end of diastolic filling when the atria contracts and fully
fills the left ventricle. Known as "atrial kick", this filling is important to
cardiac output. The increased end-diastolic volume in the ventricle
improves cardiac output. When the left ventricle is stiff (decreased
compliance with long term hypertension, aortic stenosis or with acute
STEMI), the atrium has to pump harder to move blood from the atrium
to the ventricle, causing a turbulent blood flow and extra heart sound.
This heart sound is always pathologic. It occurs before ventricular
contraction, is best heard with the bell of the stethoscope and is never a
normal heart sound, even in children.
● Which pathologic changes found on the 12-lead ECG indicate
myocardial ischemia?
A. ST-segment elevation
B. ST-segment depression and T-wave elevation
C. Q-wave formation
D. ST-segment depression and T-wave inversion. Answer: D. ST
segment depression and T wave inversion
Myocardial ischemia changes the repolarization of the ventricular
muscle. That change is seen on the 12 lead ECG as ST-segment
depression and T wave inversion, which demonstrate subendocardial
ischemia -- the innermost layer of muscle in the myocardium. ST-
segment elevation indicates acute injury or infarction, ST segment
depression and T wave elevation may indicate an electrolyte
abnormality, while Q wave formation indicates total infarction.
● Positive inotropic agents are used to:
,A. improve cardiac output and tissue perfusion
B. decrease water loss through the kidneys
C. increase heart rate
D. vasodilate vessels. Answer: A. improve cardiac output and tissue
perfusion
The term "inotropic" refers to affecting the force of myocardial
contraction. Improvement of cardiac muscle contraction leads to
improved cardiac output and tissue perfusion.
● A patient in the ED is now being admitted to telemetry bwith
complaint of chest pain and has been judged to be a possible candidate
for therapy with alteplase (Activase). Which of the following is not
considered a contraindication for the use of this medication?
A. current antibiotic use
B. recent abdominal surgery
C. recent gastrointestinal bleed
D. recent intracranial bleed. Answer: A. current antibiotic use
Use of antibiotics is not a contraindication for the use of alteplase. All
the other answers -- recent abdominal surgery, recent gastrointestinal
bleeding and a recent intracranial bleed -- are contraindications for the
use of any fibrinolytic.
● The two major components that determine blood pressure are:
A. systemic vascular resistance (SVR) (afterload) and cardiac output
, B. contractility and SVR (afterload)
C. preload and SVR (afterload)
D. contractility and SVR (afterload). Answer: A. SVR (afterload) and
cardiac output
The equation for BP is: BP = SVR x cardiac output.
BP is determined by resistance of the arterial bed and the cardiac output.
If the SVR (afterload) is high and the cardiac output low, the patient may
still have a normal BP. the pulse pressure will be lower, but this is a
compensatory response by the heart to maintain BP. If the SVR
(afterload) is low (as in early septic shock), the cardiac output is very
high, thereby trying to support BP.
● The layer of the arterial vessel wall responsible for changes in the
diameter of the artery is the:
A. media
B. intima
C. externa
D. adventitia. Answer: A. media
The media layer of the arterial wall contains vascular smooth muscle
cells and is responsible for arterial tone. Vasoactive substances released
in response to the sympathetic nervous system and/or the renin-
angiotensin system determine arterial tone. Intima, externa and
adventitia are incorrect.
SOLUTIONS GRADED A+
● A post-STEMI (ST elevation myocardial infarction) patient is started
on an angiotensin-converting enzyme (ACE) inhibitor during his
hospital stay. Which of the following is the most common serious side
effect that may occur?
A. a nonproductive cough
B. pedal edema
C. swelling of the tongue and face
D. rhinorrhea. Answer: C. swelling of the tongue and face
Although all of the answers may occur, swelling og the tongue and face
is the most serious and may require intervention. Patients should be
instructed to seek medical attention immediately for any signs of
swelling in the tongue or throat.
● Which of the following best describes the fourth heart sound (S4):
A. It occurs after ventricular contraction
B. It is best heard with the diaphragm of the stethoscope
C. It is a normal finding in children
D. It occurs during late diastole when the atria contracts. Answer: D. It
occurs during late diastole when the atria contracts
The presence of the extra heart sound S4 signifies a poorly compliant
(stiff) left ventricle. An S4 is also called an atrial heart sound since it
,occurs at the end of diastolic filling when the atria contracts and fully
fills the left ventricle. Known as "atrial kick", this filling is important to
cardiac output. The increased end-diastolic volume in the ventricle
improves cardiac output. When the left ventricle is stiff (decreased
compliance with long term hypertension, aortic stenosis or with acute
STEMI), the atrium has to pump harder to move blood from the atrium
to the ventricle, causing a turbulent blood flow and extra heart sound.
This heart sound is always pathologic. It occurs before ventricular
contraction, is best heard with the bell of the stethoscope and is never a
normal heart sound, even in children.
● Which pathologic changes found on the 12-lead ECG indicate
myocardial ischemia?
A. ST-segment elevation
B. ST-segment depression and T-wave elevation
C. Q-wave formation
D. ST-segment depression and T-wave inversion. Answer: D. ST
segment depression and T wave inversion
Myocardial ischemia changes the repolarization of the ventricular
muscle. That change is seen on the 12 lead ECG as ST-segment
depression and T wave inversion, which demonstrate subendocardial
ischemia -- the innermost layer of muscle in the myocardium. ST-
segment elevation indicates acute injury or infarction, ST segment
depression and T wave elevation may indicate an electrolyte
abnormality, while Q wave formation indicates total infarction.
● Positive inotropic agents are used to:
,A. improve cardiac output and tissue perfusion
B. decrease water loss through the kidneys
C. increase heart rate
D. vasodilate vessels. Answer: A. improve cardiac output and tissue
perfusion
The term "inotropic" refers to affecting the force of myocardial
contraction. Improvement of cardiac muscle contraction leads to
improved cardiac output and tissue perfusion.
● A patient in the ED is now being admitted to telemetry bwith
complaint of chest pain and has been judged to be a possible candidate
for therapy with alteplase (Activase). Which of the following is not
considered a contraindication for the use of this medication?
A. current antibiotic use
B. recent abdominal surgery
C. recent gastrointestinal bleed
D. recent intracranial bleed. Answer: A. current antibiotic use
Use of antibiotics is not a contraindication for the use of alteplase. All
the other answers -- recent abdominal surgery, recent gastrointestinal
bleeding and a recent intracranial bleed -- are contraindications for the
use of any fibrinolytic.
● The two major components that determine blood pressure are:
A. systemic vascular resistance (SVR) (afterload) and cardiac output
, B. contractility and SVR (afterload)
C. preload and SVR (afterload)
D. contractility and SVR (afterload). Answer: A. SVR (afterload) and
cardiac output
The equation for BP is: BP = SVR x cardiac output.
BP is determined by resistance of the arterial bed and the cardiac output.
If the SVR (afterload) is high and the cardiac output low, the patient may
still have a normal BP. the pulse pressure will be lower, but this is a
compensatory response by the heart to maintain BP. If the SVR
(afterload) is low (as in early septic shock), the cardiac output is very
high, thereby trying to support BP.
● The layer of the arterial vessel wall responsible for changes in the
diameter of the artery is the:
A. media
B. intima
C. externa
D. adventitia. Answer: A. media
The media layer of the arterial wall contains vascular smooth muscle
cells and is responsible for arterial tone. Vasoactive substances released
in response to the sympathetic nervous system and/or the renin-
angiotensin system determine arterial tone. Intima, externa and
adventitia are incorrect.
